An ongoing dialogue on HIV/AIDS, infectious diseases,
January 21st, 2014
Unanswerable Questions in Infectious Diseases: The Positive Cultures for Candida in an ICU Patient
OK, gang. You did such a bang-up job on Question #1 that I can’t resist getting another consult.
Here’s the case: Patient in intensive care, has been there for some time — at least a week, probably weeks. Perhaps he/she had surgery (especially abdominal surgery) that didn’t go well, or has severe cardiovascular disease, or multiple trauma from an MVA, or suffered a large intracerebral hemorrhage or stroke. There have been several antibiotic “courses” directed at fevers of too many origins.
Each day you see the patient, and each day there’s a fever — generally 100.5 or a bit higher. Normotensive. Nothing obvious on exam. Labs show a WBC of 11-15 — in other words, not normal but not horribly abnormal either. LFTs are fine.
All bacterial cultures are unrevealing. Several sputum cultures, however, are positive for Candida; a urine culture (from a foley catheter) is positive also. If the patient has an abdominal drain, it has a few yeast in there too. Imaging is non-specifically abnormal — some pleural effusions, but no obvious pneumonia; CT shows no abscess.
So here’s the question:
Should patients in the ICU be given systemic treatment for Candida spp. if they have positive cultures from multiple sites other than blood?
If you want to research the question, here are a couple of randomized trials here and here, concluding yay and nay, respectively.
Or just go ahead and vote, and have at it in the comments section.
8 Responses to “Unanswerable Questions in Infectious Diseases: The Positive Cultures for Candida in an ICU Patient”
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
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Good morning Dr Sax, thanks for this interesting unanswarable question regardles of the case in question. As for this patient, the most common cause of cultures being positive for yeast is having recieved multiple courses of atb, besides the fact he has a foley and an abdominal drain in which yeast are present adding that clinically he has a fever of probably “too many origins” and his/her wbc are slightly elevated and current treatment is not doing it’s job.Despite that the blood cultures are negative, there is something still unresolved. Sputum cultures hasn’t have a role since this is not an inmunocomoromissed host an we can asume that’s due to colonization. So, as i’ve learnt in my ID rotations, if you find yeast in an abdominal drain and the patient has not fully recovered its time to treat (we presume it’s candida) with fluconazol and time to complete/stop atb courses, remove the foley and maybe, if the surgeon is moody enough, remove and/or change the abdominal drain. The question that remains unclear to me is what porcentage of blood cultures for yeast are positive in this kind of patients. BTW, I have voted “yes, it’ s time to try something different”
Is it still true with the newer blood culture bottles that “50%” of patients with Candidemia will have negative cultures?
Prior blood culture techniques had a sensitivity of 50% for candidemia, current techniques have a sensitivity of around 70%. As it is the usual case in medicine, a negative result in a diagnostic tool does not equal no disease; the same applies for candidemia in the ICU.
A little background, candidemia is the third most common cause of blood stream infection in the ICU in the US; thus we need to think about it. The important thing is to risk stratify, most studies suggest that the incidence of candidemia peaks at 10 days into the ICU stay. Additionally risk factors include central lines, parenteral nutrition, immunosuppression, etc, etc. Having candida isolated from non sterile sites is another risk factor. There are some published “prediction rules”, but I don’t find them that helpful.
In patient with few risk factors for candidemia that is stable I will be inclined to watch without treatment and try “other things” first. On the other spectrum, we have the patient with multiple risk factors and “unstable”. In this latter scenario I will be inclined to treat and even with an echinocandin rather than fluconazole.
One more comment, the articles quoted for “yay” vs. “nay” are prophylaxis studies that I don’t think particularly apply to the scenario presented.
RL,
Excellent (and helpful) comment — and your point about the studies cited is valid, though one might argue (guess I would) that they are at least relevant if not directly applicable!
Paul
It all depends how sick the patient is; if patient is realy sick and septic than it would be prudent to start empiric antfungals, but if patient is relatively stable, like the one described above, i would not initiate antifungal therapy.
Patients with risk factors for systemic candidiasis (central lines, abdominal surgery, broad spectrum ABX for weeks, steroids, TPN) with otherwise unexplained leukocytosis AND multiple sites colonized with Candida spp with “failure to thrive” would warrant consideration for systemic antifungal therapy in my practice. My anecdotal experience with this is that the more they fit the profile as above, the more likely they would be to respond.
Given this scenarion I wont start antifungal. A lot of things to consider here casung fever, and that include foley cather, the drains, etc. Being clinically stable , makes it unlikely to have invasive disease. In my practice, I just usually observed the patients and institute measures to prevent colonization such as removal of drains or catheters, but vigilant monitoring for breakthrough infections
Dear Dr. Sax congratulations on your blog, extremely interesting. In my country (Argentina) usually when the ID is consulted, the intensive care medical staff, has begun the administration of fluconazole. The arguments used are prophylaxis, scores etc.. This situation is reflected in the high use of fluconazole that exist in the ICU. In this situation the ID, we must make difficult decisions such as fluconazole suspension, and if they continue treatment how long to do it?.
In my opinion on the case, I think you should reevaluate and the decision to treat or not should be based how sick the patient is